OSU Graduate Assistant Health Insurance Group No.: G Dental Choice Plus PY VAR Effective: October 01, 2014

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1 OSU Graduate Assistant Health Insurance Group No.: G Dental Choice Plus PY VAR Effective: October 01, /23/ PSGCC.OR.LG.DENTAL.0114

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3 Welcome to your PacificSource group dental plan. Your employer offers this coverage to help you and your family members stay well, and to protect you in case of illness, injury, or disease. Your plan includes a wide range of benefits and services, and we hope you will take the time to become familiar with them. Using this Handbook This handbook will help you understand how your plan works and how to use it. Please read it carefully and thoroughly. Within this handbook you ll find Dental Member Benefit Summaries for your dental plan and any other dental benefits provided under your employer s group dental policy. The summaries work with this handbook to explain your plan benefits. The handbook explains the services covered by your plan; the benefit summaries tell you how much your plan pays toward expenses and how much you re responsible for. If anything is unclear to you, the PacificSource Customer Service staff is available to answer your questions. Please give us a call, visit us on the Internet, or stop by our office. We look forward to serving you and your family. Governing Law This plan must comply with both state and federal law, including required changes occurring after the plan s effective date. Therefore, coverage is subject to change as required by law. PacificSource Customer Service Department Phone (541) or (888) cs@pacificsource.com PacificSource Headquarters PO Box 7068, Springfield, OR Phone (541) or (800) Website PacificSource.com Para asistirle en español, por favor llame el nùmero (800) , extensión This benefit book is printed on environmentally friendly paper that uses minimal chemicals and 50% fewer trees than regular paper. PacificSource is proud to align business innovation with environmental responsibility. PSGCC.OR.LG.DENTAL.0114

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5 CONTENTS DENTAL BENEFIT SUMMARY...A BECOMING COVERED...1 ELIGIBILITY... 1 ENROLLING DURING THE INITIAL ENROLLMENT PERIOD...1 ENROLLING NEW FAMILY MEMBERS...2 ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD...3 PLAN SELECTION PERIOD...5 WHEN COVERAGE ENDS...5 CONTINUATION OF INSURANCE... 5 USERRA CONTINUATION...6 COBRA CONTINUATION...6 HOW TO USE YOUR PLAN...8 COVERED EXPENSES...8 DENTAL PLAN BENEFITS...8 COVERED DENTAL SERVICES...9 CLASS I SERVICES...9 CLASS II RESTORATIVE SERVICES...9 CLASS II COMPLICATED SERVICES...10 CLASS III SERVICES...10 BENEFIT LIMITATIONS AND EXCLUSIONS...10 EXCLUDED SERVICES...10 EXCLUSION PERIODS...13 CREDIT FOR PRIOR COVERAGE...13 NECESSITY ACCORDING TO ACCEPTABLE DENTAL PRACTICE...13 INDIVIDUAL BENEFITS MANAGEMENT...13 CLAIMS PAYMENT...14 COORDINATION OF BENEFITS...15 THIRD PARTY LIABILITY...16 COMPLAINTS, GRIEVANCES, AND APPEALS...17 GRIEVANCE PROCEDURES...17 APPEAL PROCEDURES...17 HOW TO SUBMIT GRIEVANCES OR APPEALS...19 RESOURCES FOR INFORMATION AND ASSISTANCE...19 FEEDBACK AND SUGGESTIONS...19 PSGCC.OR.LG.DENTAL.0114

6 RIGHTS AND RESPONSIBILITIES...20 PRIVACY AND CONFIDENTIALITY...21 PLAN ADMINISTRATION...21 EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA)...22 DEFINITIONS...23

7 Dental Benefit Summary Dental Choice Plus PY VAR POLICY INFORMATION Group Name: Group Number: Plan Name: OSU Graduate Assistant Health Insurance G Dental Choice Plus PY VAR EMPLOYEE ELIGIBILITY REQUIREMENTS Minimum Hour Requirement: Per Employer Guidelines Waiting Period for New Employees: Per Employer Guidelines The following services may also be provided by a dental hygienist or denturist to the extent that they are operating within the scope of their license as required under law in the state of issuance. Eligible charges are limited to the usual, customary, and reasonable charges of dental providers in the same service area for similar treatment of similar dental conditions. Advantage Network dentists agree to write off any charges over and above negotiated, contracted fees for most services. When you use an Advantage Network dentist, you will not be responsible for any excess charges and will pay only your plan s coinsurance amount. If you choose not to use a participating dentist, or don t have access to them, reimbursement is based on the 85 th percentile of the Advantage Network fee schedule. If those charges exceed the fee schedule, the excess charges are your responsibility. This plan covers dental services for members through age 18 as required under the Affordable Care Act. Annual Deductible Per Person, Per Contract Year Per Family, Per Contract Year All Providers $50 $150 Annual Benefit Maximum $2,500 per person per contract year. Applies to all covered services. The member is responsible for the above deductible and the following co-insurance. Service All Providers Class I Services Examinations Bitewing films, full mouth x-rays and/or panorex Dental cleaning (prophylaxis and periodontal maintenance) Topical fluoride Fluoride varnish Sealants Space maintainers Athletic mouth guards Brush biopsies No charge* No charge* No charge* No charge* No charge* No charge* No charge* No charge* No charge* Class II Services - Restorative Treatment Fillings Simple surgical extractions Periodontal scaling 20% co-insurance 20% co-insurance 20% co-insurance PSGBS.OR.LG.DENTAL.0114 A

8 Root planing and/or curettage Full mouth debridement Class II Services - Complicated Treatment Complicated oral surgery Pulp capping Pulpotomy Root canal therapy Periodontal surgery Tooth desensitization Class III Services Crowns Replacement of existing prosthetic device Dentures Bridges 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 50% co-insurance 50% co-insurance 50% co-insurance 50% co-insurance This is a brief summary of benefits. Refer to your handbook for additional information or a further explanation of benefits, limitations, and exclusions. * Not subject to annual deductible. PSGBS.OR.LG.DENTAL.0114 B

9 Additional Information What is the annual deductible? Your plan s deductible is the amount of money that you pay first, before your plan starts to pay. You ll see on the Dental Benefit Summary that some services are covered by the plan without you needing to meet the deductible. In addition to the individual deductible, your plan also has a family deductible and we will credit you with whichever deductible you meet first. For the family deductible, if the combined expenses of three or more family members meet the family deductible amount, then every member of the family is considered to have met their plan s deductible for the year. Participating provider expense and non-participating provider expense apply together toward your deductibles. What is the annual benefit maximum? The Annual Benefit Maximum is the maximum amount payable by this policy for covered services received each contract year. PSGBS.OR.LG.DENTAL.0114 C

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11 BECOMING COVERED ELIGIBILITY Employees You are eligible if you are employed by the Oregon State University and meet certain requirements. Please see your plan administrator for the specific requirements to determine eligibility. Family members While you are insured under this plan, the following family members are also eligible for coverage: Your legal spouse or qualified domestic partner. Your, your spouse's, or your qualified domestic partner's natural or step children under age 26 regardless of the child's place of residence, marital status, or financial dependence on you. Your, your spouse s, or your qualified domestic partner s unmarried dependent children age 26 or over who are mentally or physically disabled. To qualify as dependents, they must have been continuously unable to support themselves since turning age 26 because of a mental or physical disability. PacificSource requires documentation of the disability from the child s physician, and will review the case before determining eligibility for coverage. A child placed for adoption with you, your spouse, or your qualified domestic partner. Placement for adoption means the assumption and retention by you, your spouse, or qualified domestic partner of a legal obligation for full or partial support and care of the child in anticipation of adoption of the child. Coverage will continue assuming continued eligibility under this plan unless placement is disrupted prior to legal adoption and the child is removed from placement. A foster child placed with you, your spouse, or your qualified domestic partner. Placement means an individual who is placed by an authorized placement agency or by judgment, decree, or other order of any court of competent jurisdiction. Coverage will continue assuming continued eligibility under this plan unless placement is disrupted and the child is removed from placement. A child placed in your, your spouse s, or your qualified domestic partner s guardianship. To be eligible for coverage, the child must be unmarried; not in a qualified domestic partnership; related to you by blood, marriage, or qualified domestic partnership; under age 19; AND for whom you are the court appointed legal custodian or guardian with the expectation the child will live in your household for at least a year and for whom the subscriber or subscriber s spouse or qualified domestic partner provides at least 50 percent support. It may also include any grandchildren under age 19 you are financially responsible for, who are unmarried and expected to live in your household for at least a year. No family or household members other than those listed above are eligible to enroll under your coverage. ENROLLING DURING THE INITIAL ENROLLMENT PERIOD Once you satisfy your employer s probationary waiting period, and meet the hours required for eligibility, you and/or your eligible family members become eligible for this plan. Starting on the date you become eligible, you and/or your family members have 45 days to enroll. We call this 45 day window the initial enrollment period. To enroll you must complete and sign an enrollment application provided by your employer. Return the application to your employer, and your employer will send to PacificSource. If you miss your initial enrollment period, you will not be able to enroll in the plan later in the year, unless you have a special circumstance, called a 'qualifying event'. (For more information, see 'Special Enrollment Periods' and 'Late Enrollment' under the Enrolling After the Initial Enrollment Period section.) PSGCC.OR.LG.DENTAL

12 The 'initial enrollment period' is the 45 day period beginning on the date a person is first eligible for enrollment in this plan. Everyone who becomes eligible for coverage has an initial enrollment period. Coverage begins on the first day of the term for which the student receives at least a 0.20 FTE appointment provided a completed enrollment form is received by the OSU Insurance Liaison Office, 328 Student Health Services, Plagemand Building, within 45 days of the appointment. For purpose of the group health policy, the first day of each term is defined as follows: Fall: October 1 Winter: January 1 Spring: April 1 Summer: July 1 In the event of a late assistantship, the effective date will instead be determined by the date the offer was made. A graduate assistantship with an effective date prior to the 16th of a month will be effective the first of the month within the same term. Eligibility for a graduate assistantship with an effective date on or after the 16th of the month will begin on the first day of the following month. ENROLLING NEW FAMILY MEMBERS Newborns Your newborn child is eligible from the moment of birth for 31 days. If you wish to continue providing coverage for the child beyond 31 days, you must enroll them on the plan. To enroll the child, PacificSource must receive your completed enrollment application and any additional premium from your employer within 45 days of birth. If additional premium is required, it is charged from the date of birth or placement and prorated for the first month. A claim for maternity care is not considered notification for the purpose of enrolling a newborn child. Anytime there is a delay in providing enrollment information, PacificSource may ask for legal documentation to confirm validity. Adopted Children When a child is placed in your home for adoption, you have 45 days from the date of placement to enroll them in your plan. To enroll the child, PacificSource must receive your completed enrollment application and any additional premium from your employer within 45 days of the placement. If additional premium is required, it is charged from the date of birth or placement and prorated for the first month. Coverage for your new family members will begin on the date of placement. You may be required to submit a copy of the certificate of adoption or other legal documentation from a court or a child placement agency to complete enrollment. Foster Children When a foster child is placed in your home, you have 45 days from the date of placement to enroll them in your plan. To enroll the child, PacificSource must receive your completed enrollment application and any additional premium from your employer within 45 days of the placement. If additional premium is required, it is charged from the date of birth or placement and prorated for the first month. Coverage for your new family members will begin on the date of placement. You may be required to submit a copy of the legal documentation from a court or a child placement agency to complete enrollment. Family Members Acquired by Marriage If you marry, you have 45 days from the date of the marriage to enroll your new spouse and any newly eligible dependent children in your plan. PacificSource must receive your completed enrollment application and any additional premium from your employer within 45 days of the marriage. Coverage for your new family members will then begin on the first day of the month after the marriage. You may be required to submit a copy of your marriage certificate to complete enrollment. Family Members Acquired by Qualified Domestic Partnership If you and your same-gender domestic partner have been issued a Certificate of Registered Domestic Partnership, your domestic partner and your partner s dependent children are eligible for coverage during the 45 day initial enrollment period after the registration of the domestic partnership. PacificSource must receive your completed enrollment application and additional premium during the initial enrollment period. Coverage PSGCC.OR.LG.DENTAL

13 for your new family members will then begin on the first day of the month after the registration of the domestic partnership. You may be required to submit a copy of your Certificate of Registered Domestic Partnership to complete enrollment. Unregistered domestic partners and their children may also become eligible for enrollment. If you and your unregistered domestic partner meet the criteria on the Affidavit of Domestic Partnership supplied by your employer, your domestic partner and your partner s dependent children are eligible for coverage during the 45 day initial enrollment period after the requirements of the Affidavit of Domestic Partnership are satisfied. PacificSource must receive your completed enrollment application, a copy of your Affidavit of Domestic Partnership, and additional premium during the initial enrollment period. Coverage for your new family members will then begin on the first day of the month after the Affidavit of Domestic Partnership is received by PacificSource. Family Members Placed in Your Guardianship If a court appoints you custodian or guardian of an eligible dependent child, you have 45 days from the court appointment to enroll them in your plan. PacificSource must receive your completed enrollment application and any additional premium from your employer within 45 days of the court appointment. Coverage will then begin on the first day of the month after the date of the court order. You may be required to submit a copy of the court order to complete enrollment. When the court order terminates or expires, the child is no longer an eligible child. Qualified Medical Child Support Orders This dental plan complies with qualified medical child support orders (QMCSO) issued by a state court or state child support agency. A QMCSO is a judgment, decree, or order, including approval of a settlement agreement, which provides for dental benefit coverage for the child of a plan member. If a court or state agency orders coverage for your spouse, qualified domestic partner, or child, you have 45 days from the date of the court order to enroll them in this plan. PacificSource must receive your completed enrollment application and any additional premium from your employer within 45 days of the court order. Coverage will become effective on the first day of the month after the court order. You may be required to submit a copy of the QMCSO to complete enrollment. ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD Returning to Work after a Layoff If you are laid off and then rehired by your employer within three months, you will not have to satisfy another probationary waiting period. Your dental coverage will resume the day you return to work and again meet your employer s minimum hour requirement. If your family members were covered before your layoff, they can resume coverage at that time as well. You must re-enroll your family members by submitting an enrollment application within the 45 day initial enrollment period following your return to work. If the employee s exclusion period were satisfied (or partially satisfied) before the layoff, they will be credited at the same level when the employee returns to work. However, your family members will be subject to a new exclusion period unless they had creditable coverage during a layoff of more than 63 days. For information about creditable coverage, please see 'Exclusion Periods' and Credit for Prior Coverage in the Benefit Limitations and Exclusions section of this handbook. Returning to Work after a Leave of Absence If you return to work after an employer-approved leave of absence of three months or less, you will not have to satisfy another probationary waiting period.your dental coverage will resume the day you return to work and again meet your employer s minimum hour requirement. If your family members were covered before your leave of absence, they can resume coverage at that time as well. You must re-enroll your family members by submitting an enrollment application within the 45 day initial enrollment period following your return to work. Both you and your family members will be subject to a new exclusion period unless you had creditable coverage during a leave of absence of more than 63 days. For information about creditable coverage, please PSGCC.OR.LG.DENTAL

14 see see 'Exclusion Periods' and 'Credit for Prior Coverage' in the Benefit Limitations and Exclusions section of this handbook. Returning to Work after Family Medical Leave If you work for a company that employs 50 or more people, your employer is probably subject to the Family Medical Leave Act (FMLA). To find out if you have rights under FMLA, ask your dental plan administrator. Under FMLA, if you return to work after a qualifying FMLA medical leave, you will not have to satisfy another probationary waiting period or any previously satisfied exclusion period under this plan. Your dental coverage will resume the day you return to work and meet your employer s minimum hour requirement. If your family members were covered before your leave, they can also resume coverage at that time if you re-enroll them within the 45 day initial enrollment period following your return. Special Enrollment Periods If you enroll during your initial enrollment period, your family members may decline coverage, and they may enroll in the plan later if they qualify under the Special Enrollment Rules below. In accordance with your employer's guidelines, both you and your family members may decline coverage when you are first eligible. If you choose to decline coverage, your must complete an OSU Student Insurance Waiver within 45 days of your graduate teaching appointment. Employees are allowed to waive medical coverage and enroll in dental only if the employee has an eligible waiver. OSU allows you to waive coverage only under the following situations (see OSU for more detailed requirements): If you are sponsored by your embassy If you are covered as a U.S. based employee, or as a dependent of a U.S. based employee To waive this coverage, an employee must complete a waiver form and have adequate equivalent or better coverage that covers both emergent and non-emergent care. This coverage must include medical, vision, dental, and pharmacy coverage. This coverage may not be waived to coverage obtained outside the United States. The employee's other coverage must be reviewed and approved by the OSU Student Health Insurance office. You and/or your dependents may enroll under this dental plan if the enrollment coincides with a permissible enrollment event according to the terms of a group dental policy sponsored by your employer. Enrollment events may include an involuntary loss of other coverage, marriage, registration of a domestic partnership, birth of a child, adoption of a child, coverage ordered by a court or state agency, or enrollment allowed by a leave of absence or layoff rehire provision. Child turning two years of age. If you declined enrollment in this plan s coverage for your newborn or child under 24 months of age, you may enroll that child upon turning two years of age. To enroll your child, you must request enrollment and pay any required premium by the last day of the month in which they turn two years old. Coverage becomes effective for your child the first day of the month following receipt of the application. Late Enrollment If you did not enroll during your initial enrollment period and you do not qualify for a special enrollment period, your enrollment will be delayed until the plan s next designated open enrollment period. A late enrollee is an otherwise eligible employee or family member who does not qualify for a special enrollment period explained above, and who: Did not enroll during the initial enrollment period; or Enrolled during the initial enrollment period but discontinued coverage later. PSGCC.OR.LG.DENTAL

15 You may enroll yourself or your family member as a 'late enrollee' by submitting an enrollment application to your employer during one of the following open enrollment periods designated by your employer: For applications received between September 16-30, enrollment becomes effective October 1. For applications received between December 16-31, enrollment becomes effective January 1. For applications received between March 16-31, enrollment becomes effective April 1. For applications received between June 16-30, enrollment becomes effective July 1. The plan s exclusion periods apply from the date of coverage unless you have prior creditable coverage (see 'Credit for Prior Coverage' in the Benefit Limitations and Exclusions section of this handbook). PLAN SELECTION PERIOD If your employer offers more than one benefit plan option, you may choose another plan option only upon your plan's anniversary date. You may select a different plan option by completing a selection form or application form. Coverage under the new plan option becomes effective on your plan s anniversary date. WHEN COVERAGE ENDS If you leave your job for any reason or your work hours are reduced below your employer s minimum requirement, coverage for you and your enrolled family members will end. Coverage ends on the last day of the last month in which you worked full time and for which a premium was paid. You may, however, be eligible to continue coverage for a limited time; please see the Continuation section of this handbook for more information. You can voluntarily discontinue coverage for your enrolled family members at any time by completing a Termination of Dependent Coverage form and submitting it to your employer. Keep in mind that once coverage is discontinued, your family members may be subject to the late enrollment waiting period if they wish to re-enroll later. Divorced Spouses If you divorce, coverage for your spouse will end on the last day of the month in which the divorce decree or legal separation is final. You must notify your employer of the divorce or separation, and continuation coverage may be available for your spouse. If there are special child custody circumstances, please contact the PacificSource Membership Services Department. Please see the Continuation section for more information. Dependent Children When your enrolled child no longer qualifies as a dependent, their coverage will end on the last day of that month. Please see Eligibility in the Becoming Covered section of this handbook for information on when your dependent child is eligible beyond age 25. The Continuation section includes information on other coverage options for those family members who no longer qualify for coverage. Dissolution of Qualified Domestic Partnership If you dissolve your qualified domestic partnership, coverage for your qualified domestic partner and their children not related to you by birth or adoption will end on the last day of the month in which the dissolution of the qualified domestic partnership is final. You must notify your employer of the dissolution of the qualified domestic partnership, and continuation coverage may be available for your domestic partner. Qualified domestic partners and their covered children are not recognized as qualified beneficiaries under federal COBRA continuation laws. Qualified domestic partners and their covered children may not continue this policy s coverage under COBRA independent of the employee (see COBRA Continuation in the Continuation of Insurance section). CONTINUATION OF INSURANCE Under federal law, you and your family members may have the right to continue this plan s coverage for a specified time. You and your family members may be eligible if: PSGCC.OR.LG.DENTAL

16 Your employment ends or you have a reduction in hours You take a leave of absence for military service You divorce or dissolve your qualified domestic partnership You die Your children no longer qualify as dependents The following sections describe your rights to continuation under federal law, and the requirements you must meet to enroll in continuation coverage. USERRA CONTINUATION If you take a leave of absence from your job due to military service, you have continuation rights under the Uniformed Services Employment and Re-employment Rights Act (USERRA). You and your enrolled family members may continue this plan s coverage if you, the employee, no longer qualify for coverage under the plan because of military service. Continuation coverage under USERRA is available for up to 24 months while you are on military leave. If your military service ends and you do not return to work, your eligibility for USERRA continuation coverage will end. Premium for continuation coverage is your responsibility. The following requirements apply to USERRA continuation: Family members who were not enrolled in the group plan cannot take continuation. The only exceptions are newborn babies and newly acquired eligible family members not covered by another group health plan. To apply for continuation, you must submit a completed Continuation Election Form to your employer within 45 days after the last day of coverage under the group plan. You must pay continuation premium to your employer by the first of each month. Your employer will include your continuation premium in the group s regular monthly payment. PacificSource cannot accept the premium directly from you. Your employer must still be insured by PacificSource. If your employer discontinues this plan, you will no longer qualify for continuation. COBRA CONTINUATION If you work for an employer that has 20 or more employees, your employer is probably subject to the continuation of coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as amended. To find out if you have continuation rights under COBRA, ask your dental plan administrator. COBRA Eligibility If, as an active employee, you were required to enroll in a medical plan as well as this dental plan, you may continue coverage under this dental plan if you also continue coverage under the medical plan. If, as an active employee, you enrolled in only the dental plan, you may continue coverage under the dental plan according to the following: A qualifying event is the event that causes your regular group coverage to end and makes you eligible for continuation coverage. When the following qualifying events happen, you may continue coverage for the lengths of time shown: PSGCC.OR.LG.DENTAL

17 Qualifying Event Continuation Period Employee s termination of employment or reduction in hours Employee, spouse, and children may continue for up to 18 months 1 Employee s divorce Spouse and children may continue for up to 36 months 2 Employee s eligibility for Medicare benefits if it causes a loss of coverage Spouse and children may continue for up to 36 months Employee s death Spouse and children may continue for up to 36 months 2 Child no longer qualifies as a dependent Child may continue for up to 36 months 2 1 If the employee or covered family member is determined disabled by the Social Security Administration within the first 60 days of COBRA coverage, all qualified beneficiaries may continue coverage for up to 29 months. 2 The total maximum continuation period is 36 months, even if there is a second qualifying event. A second qualifying event might be a divorce, death, or child no longer qualifying as a dependent after the employee s termination or reduction in hours. If your family members were not covered prior to your qualifying event, they may enroll in the continuation coverage while you are on continuation. They will be subject to the same rules that apply to active employees, including the late enrollment waiting period. If your employment is terminated for gross misconduct, you and your family members are not eligible for COBRA continuation. When Continuation Coverage Ends Your continuation coverage will end before the end of the continuation period above if any of the following occur: Your continuation premium is not paid on time. Your employer discontinues its dental plan and no longer offers a group dental plan to any of its employees. Your continuation period was extended from 18 to 29 months due to disability, and you are no longer considered disabled. Type of Coverage Under COBRA, you may continue any coverage you had before the qualifying event. If your employer provides both medical and dental coverage and you were enrolled in both, you may continue both medical and dental. If your employer provides only one type of coverage, or if you were enrolled in only one type of coverage, you may continue only that coverage. COBRA continuation benefits are always the same as your employer s current benefits. Your employer has the right to change the benefits of its dental plan or eliminate the plan entirely. If that happens, any changes to the group dental plan will also apply to everyone enrolled in continuation coverage. Your Responsibilities and Deadlines You must notify your employer within 60 days if you divorce, or if your child no longer qualifies as a dependent. That will allow your employer to notify you or your family members of your continuation rights. When your employer learns of your eligibility for continuation, your employer will notify you of your continuation rights and provide a Continuation Election Form. You then have 60 days from that date or 60 days from the date coverage would otherwise end, whichever is later, to enroll in continuation coverage by submitting a completed Election Form to your employer. If continuation coverage is not elected during that 60 day period, coverage will end on the last day of the last month you were an active employee. If you or your employer do not provide these notifications within the time frames required by COBRA, PacificSource s responsibility to provide coverage under the group policy will end. Continuation Premium PSGCC.OR.LG.DENTAL

18 You or your family members are responsible for the full cost of continuation coverage. Your employer uses the services of a third-party COBRA administrator to collect premium for continuation coverage. Please see your employer for more information about your plan s COBRA administrator. The monthly premium must be paid to your plan s COBRA administrator. PacificSource cannot accept continuation premium directly from you. You may make your first premium payment any time within 45 days after you return your Continuation Election Form to your plan s COBRA administrator. After the first premium payment, each monthly payment must reach your plan s COBRA administrator within 30 days of your plan s COBRA administrator premium due date. If your plan s COBRA administrator does not receive your continuation premium on time, continuation coverage will end. If your coverage is canceled due to a missed payment, it will not be reinstated for any reason. Premium rates are established annually and may be adjusted if the plan s benefits or costs change. WORK STOPPAGE Labor Unions If you are a union member, you have certain continuation rights in the event of a labor strike. Your union is responsible for collecting your premium and can answer questions about coverage during the strike. HOW TO USE YOUR PLAN When you need dental care, you may visit any dentist. Most dental offices will bill PacificSource directly. If your dentist has any questions regarding billing procedures, he or she can call PacificSource toll-free at (888) When you first visit your dentist after becoming covered under this plan, let the office staff know you have dental benefits through PacificSource. You will need to show your PacificSource ID card, which contains your group number and benefit information. Your dentist may submit claims and treatment programs on a standard American Dental Association form. For extensive dental work, we recommend that your dentist submit a pre-treatment estimate to PacificSource. We then determine how much your plan will pay toward the proposed treatment and review the estimate with your dentist prior to treatment. If your covered family members require extensive dental work, be sure your member ID number and group number are included on their pre-treatment form for identification purposes. COVERED EXPENSES DENTAL PLAN BENEFITS When this plan pays for dental services, it actually pays the stated percentage of charges based on reasonable and customary charges. A charge is reasonable and customary when it falls within a general range of charges being made by most dental providers in your service area for similar treatment of similar dental conditions. If the charge for a treatment or service is more than the reasonable and customary charge in your service area, you may be required to pay the difference. The reasonable and customary charge for dental expense is the covered charge referred to in this booklet. If you or your covered family member selects a more expensive treatment than is customarily provided, this plan will pay the applicable percentage of the lesser fee. You will be responsible for the balance of the provider s charges. With the Advantage Network, participating dentists agree to write off any charges over and above the negotiated, contracted fees for most services. When you use a participating dentist in the Advantage Network, you will not be responsible for any excess charges and will pay only your plan s deductible and/or co-insurance amount. If you choose not to use a participating Advantage Network dentist, or don t have access to them, reimbursement will continue to be based on usual, customary, and reasonable (UCR) charges. If that non-participating dentist s fees exceed the UCR charges, the excess charges are also your responsibility. Subject to all the terms of this policy, incurred dental expense for the following services and supplies are covered according to the Dental Benefit Summary. Benefits are eligible for payment only to the extent a charge is, or would be, made for the least costly service or supply appropriate to your dental treatment. PSGCC.OR.LG.DENTAL

19 Charges in excess of the least costly service or supply appropriate for treatment or the usual, customary and reasonable fee are not covered under this policy and become your responsibility. COVERED DENTAL SERVICES This dental plan covers the following services when performed by an eligible provider and when determined to be necessary by the standards generally accepted dental practice for the prevention or treatment of oral disease or for accidental injury, including masticatory function. Covered services may also be provided by a dental hygienist or denturist to the extent that he or she is operating within the scope of his or her license as required under law in the State of Oregon. Covered dental services are organized into three classes, starting with preventive care and advancing into specialized dental treatments. CLASS I SERVICES Benefits for examinations (routine or other diagnostic exams) are limited to two examinations per person per contract year. Separate charges for review of a proposed treatment plan or for diagnostic aids, such as study models and certain lab tests, are not covered. Problem focused examinations are limited to two per contract year. Benefits for full mouth x-rays and/or panorex are limited to one complete mouth series and/or panorex in any 36 month period and further limited to four bite-wing films in a six month period. When an accumulative charge for additional periapical x-rays in a one year period matches that of a complete mouth series, no further benefits for periapical x-rays or panorex are available for the remainder of the year. Benefits for dental cleaning (prophylaxis and periodontal maintenance) are limited to a combined total of three procedures per person per contract year. The limitation for dental cleaning applies to any combination of prophylaxis and/or periodontal maintenance in the contract year. A separate charge for periodontal charting is not a covered benefit. Periodontal maintenance is not covered when performed within three months of periodontal scaling and root planing and/or curettage. Benefits for the topical application of fluoride are limited to two applications per contract year. Benefits for fluoride varnish applications are limited to four applications per contract year for members through age 18. Benefits for the application of sealants are limited to one application in a 36 month period to permanent molars and bicuspids and only for members through age 18. Benefits for space maintainers are covered for members through age 18. Benefits for athletic mouth guards are limited to one per lifetime through age 18 if the member is still enrolled in secondary school. Benefits for brush biopsies used to aid in the diagnosis of oral cancer are covered. CLASS II RESTORATIVE SERVICES Benefits for a composite, resin, or similar restoration in a posterior (back) tooth are limited to the amount that would be paid for a corresponding amalgam restoration. A separate charge for anesthesia when used during restorative procedures is not a covered benefit. Only one filling is allowed per tooth surface. PacificSource will pay for a filling on a tooth surface only once per contract year. Three or more surface fillings are limited to one per surface per contract year. Simple surgical extractions of teeth and other minor oral surgery procedures are covered. General anesthesia used in conjunction with these extractions administered by a dentist in a dental office is also covered. A separate charge for alveolectomy performed in conjunction with removal of teeth is not a covered benefit. PSGCC.OR.LG.DENTAL

20 Benefits for periodontal scaling and root planing and/or curettage are limited to only one procedure per quadrant in any 36 month period. For the purpose of this limitation, eight or fewer teeth existing in one arch will be considered one quadrant. Benefits for full mouth debridement are limited to once every 24 months. This procedure is only covered if the teeth have not received a prophylaxis in the prior 24 months and if an evaluation cannot be performed due to the obstruction by plaque and calculus on the teeth. This procedure is not covered if performed on the same date as the prophylaxis. CLASS II COMPLICATED SERVICES Complicated oral surgery procedures such as the removal of impacted teeth are limited to procedures that have been preauthorized by PacificSource. Benefits for complicated oral surgery procedures include general anesthesia administered by a dentist in a dental office. A separate charge for alveolectomy performed in conjunction with removal of teeth is not a covered benefit. Benefits for pulp capping are payable only when there is an exposure to the pulp. These are direct pulp caps. Indirect pulp caps are not covered. Benefits for a pulpotomy are payable only for deciduous teeth. Benefits for root canal therapy on the same tooth are payable only for one charge in a 36 month period. Benefits for periodontal surgery are limited to procedures that have been preauthorized by PacificSource and accompanied by a periodontal diagnosis and history of conservative (non-surgical) periodontal treatment. Benefits for tooth desensitization are covered as a separate procedure from other dental treatment. CLASS III SERVICES Benefits for crowns and other cast or laboratory-processed restorations are limited to the restoration of any one tooth in a 60 month period. If a tooth can be restored with a material such as amalgam or composite resin, covered charges are limited to the cost of amalgam or non-laboratory composite resin restoration even if another type of restoration is selected by the patient and/or dentist. Benefits for the replacement of an existing prosthetic device are provided only when the device being replaced is unserviceable, cannot be made serviceable, and has been in place for at least 60 months. Benefits for any cast partial denture, full denture, immediate denture, or overdenture are limited to the cost of a standard full or cast partial denture. A separate charge for denture adjustments and relines performed within six months of the initial placement is not a covered benefit. Benefits for subsequent relines are provided only once in a 12 month period. Cast restorations for partial denture abutment teeth or for splinting purposes are not covered unless the tooth in and of itself requires a cast restoration. Benefits for fixed bridges or removable cast partials are covered once every 120 months. Benefits for temporary full or partial dentures must be preauthorized by PacificSource. Benefits for the initial placement of full or partial dentures or fixed bridges (including acid-etch metal bridges) are provided only if the denture or bridgework includes replacement of a natural tooth which has been extracted or lost while the member s coverage is in effect. However, this limitation does not apply after the member has been covered under the policyholder s group dental plan for a period of at least 36 consecutive months. BENEFIT LIMITATIONS AND EXCLUSIONS EXCLUDED SERVICES This plan does not provide benefits in any of the following circumstances or for any of the following conditions: PSGCC.OR.LG.DENTAL

21 Aesthetic dental procedures - Services and supplies provided in connection with dental procedures that are primarily aesthetic, including bleaching of teeth and labial veneers Antimicrobial agents - Localized delivery of antimicrobial agents into diseased crevicular tissue via a controlled release vehicle Athletic activities - Any injuries sustained while competing or practicing for a professional or semiprofessional athletic contest Biopsies or histopathologic exams - (except when related to tooth structure and preauthorized) Bone replacement grafts to prepare sockets for implants after tooth extraction Charges for broken appointments Collection of cultures and specimens Connector bar or stress breaker Core build-ups are not covered unless used to restore a tooth that has been treated endodontically (root canal). Cosmetic/reconstructive services and supplies - Procedures, appliances, restorations, or other services that are primarily for cosmetic purposes. This includes services or supplies rendered primarily to correct congenital or developmental malformations, including but not limited to, peg laterals, cleft palate, maxillary and mandibular (upper and lower jaw) malformation, enamel hypoplasia, veneers, and fluorosis (discoloration of teeth). However, the replacement of congenitally missing teeth is covered. Denture replacement made necessary by loss, theft, or breakage Diagnostic casts - Diagnostic casts (study models), gnathological recordings, occlusal appliances, occlusal equilibration procedures, or similar procedures Drugs and medications that are prescribed drugs, premedication drugs, analgesics (e.g., non-intravenous sedation), any other euphoric drugs, or any take-home medicine or supplies distributed by a provider Educational programs - Instructions and/or training in plaque control and oral hygiene Experimental or investigational procedures - Services, supplies, protocols, procedures, devices, drugs or medicines, or the use thereof that are experimental or investigational for the diagnosis and treatment of the patient. An experimental or investigational service is not made eligible for benefits by the fact that other treatment is considered by the member s dental care provider to be ineffective or not as effective as the service or that the service is prescribed as the most likely to prolong life. Fractures of the mandible - Services and supplies provided in connection with the treatment of simple or compound fractures of the mandible General anesthesia except when administered by a dentist in connection with oral surgery in his/her office Gingivectomy, gingivoplasty or crown lengthening in conjunction with crown preparation or fixed bridge services done on the same date of service Hospital charges or additional fees charged by the dentist for hospital treatment Hypnosis Implants - Surgical preparation, surgical placement, or removal of implants Indirect pulp caps are to be included in the restoration process, and are not a separate covered benefit. Infection control - A separate charge for infection control or sterilization Intra and extra coronal splinting - Devices and procedures for intra and extra coronal splinting to stabilize mobile teeth Oral surgery treating any fractured jaw PSGCC.OR.LG.DENTAL

22 Orthodontic services - Repair or replacement of orthodontic appliances furnished under this plan. Orthognathic surgery - Surgery to manipulate facial bones, including the jaw, in patients with facial bone abnormalities performed to restore the proper anatomic and functional relationship to the facial bones Periodontal probing, charting, and re-evaluations Photographic images Pin retention in addition to restoration. Precision attachments Removal of clinically serviceable amalgam restorations to be replaced by other materials free of mercury, except with proof of allergy to mercury Services covered by the member s medical plan Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth Services otherwise available - These include but are not limited to: Services or supplies for which payment could be obtained in whole or in part if the member applied for payment under any city, county, state, or federal law (except Medicaid); Services or supplies the member could have received in a hospital or program operated by a federal government agency or authority. Covered expenses for services or supplies furnished to a member by the Veterans Administration of the United States that are not service-related are eligible for payment according to the terms of this plan; and Services or supplies for which payment would be made by Medicare. Services or supplies for which no charge is made, which you are not legally required to pay, or which a provider or facility is not licensed to provide even though the service or supply may otherwise be eligible. This includes services provided by you or an immediate family member. Services or supplies provided outside of the United States, except in cases of emergency Services, supplies, and treatment resulting from an illegal occupation or attempted felony, or treatment received while in the custody of any law enforcement authority Sinus lift grafts to prepare sinus site for implants Stress-breaking or habit-breaking appliances Temporomandibular joint - Services or supplies for treatment of any disturbance of the temporomandibular joint Third party liability, motor vehicle liability, motor vehicle insurance coverage, workers compensation - Any services or supplies for illness or injury for which a third party is responsible or which are payable by such third party or which are payable pursuant to applicable workers compensation laws, motor vehicle liability, uninsured motorist, underinsured motorist, and personal injury protection insurance and any other liability and voluntary medical payment insurance to the extent of any recovery received from or on behalf of such sources. Tooth transplantation - Services and supplies provided in connection with tooth transplantation, including re-implantation from one site to another and splinting and/or stabilization. This exclusion does not relate to the re-implantation of a tooth into its original socket after it has been avulsed. Treatment after insurance ends - Services or supplies provided after enrollment in this plan ends, except as provided for under Extension of Benefits in the Plan Benefits section. The only exception is for Class III Services ordered and fitted before enrollment ends and are placed within 31 days after enrollment ends. Treatment not dentally necessary according to acceptable dental practice or treatment not likely to have a reasonably favorable prognosis. PSGCC.OR.LG.DENTAL